Reclaiming Your Life, Inc. Intake
Reclaiming Your Life, Inc. is a non-profit organization dedicated to supporting survivors and their families who have experienced domestic violence and those healing from past trauma. Our mission is to provide a safe, nurturing environment where individuals can rebuild their lives, find strength, and gain the tools needed for personal growth and empowerment. Through our comprehensive programs, including transitional housing, counseling, workshops, and support groups, we aim to foster resilience and facilitate lasting change. Please provide the following information to help us better understand your needs and how we can support you on your journey to reclaim your life. Thank you for your interest in our Virtual Career Development & Financial Literacy Program, designed for families who have experienced domestic violence. This application is confidential. Please complete the form to the best of your ability. If you have any concerns about safety or privacy, contact us at intake@rylcorp.org for assistance.
Name
*
First Name
Last Name
Date of Birth:
*
-
Month
-
Day
Year
00/00/0000
Phone Number
*
Please enter a valid phone number.
Safe to call/leave voicemail?
*
Yes
No
Email
*
example@example.com
Safe to email?
*
Yes
No
Safe to text?
*
Yes
No
Preferred method of contact if an urgent safety issue arises.
*
Phone
Email
Text
Mailing Address (we will not send you mail without your permission)
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do you prefer not to share your current address?
Yes
No
Emergency Contact
*
Full Name
Relationship
Phone Number
State / Province
Postal / Zip Code
Are you currently in a safe environment?
*
Yes
No
Are you a survivor of domestic violence?
*
Yes
No
Are you currently experiencing any form of abuse?
*
Yes
No
Do you have children or dependents?
*
Yes
No
If yes, how many children/dependents do you have?
Household Size:
Living Situation
*
Shelter
Transitional Housing
Staying w/Friends or Family
Renting
Martial Status:
*
Single
Married
Seperated
Divorce
Widow
Household Income:
*
Under $15,000
$15,000 to $24,999
$25,000 to $34,999
$35,000 to $49,999
$50,000 to $74,999
$75,000 and above
Please select the services you are interested in?
*
Career Development
Financial Literacy
Support Groups
Are you employed?
Yes
No
Do you have an updated résumé?
Yes
No
Not sure
What types of jobs/careers are you interested in or have experience with? (if unsure or none please type n/a)
What financial topics are you most interested in?
Budgeting
Credit repair
Saving
Have you participated in any financial literacy programs before?
Yes
No
If yes, please provide details:
Highest level of education completed
High School Diploma
GED
College
Trade School
Other
Do you have access to a reliable internet connection?
Yes
No
Do you have a computer, laptop, or smartphone you can use for virtual sessions?
Yes
No
Primary language spoken at home
Do you need an interpreter or translated materials?
Yes
No
N/A
Do you have any immediate needs we should be aware of?
Yes
No
If yes, please briefly describe:
Do you consent to our team contacting you with program updates and scheduling information?
Yes
No
How did you hear about Reclaiming Your Life, Inc.?
Please select the services you would be interested in the furture?
Mental Health (i.e. therapist)
Self-Care
Coaching/Mentoring
Support Groups
SIP & Talk
Retreats/Workshops
Program Expectations & Participation Agreement
Our program involves attending virtual workshops, completing assignments, and participating in one-on-one coaching sessions. We are committed to supporting you and your family’s unique journey. Please review the agreement below.
I understand that regular attendance is essential to achieve the best outcomes.
*
Yes
No
I understand all information shared will be kept confidential unless there is a concern of imminent harm or required legal reporting.
*
Yes
No
I agree to provide feedback and updates throughout the program, so we can tailor resources to my family’s needs.
*
Yes
No
Electronic Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit
Submit
Should be Empty: